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_1 j lc.' lln IC :i ;;i j r <br /> i � � ^� _ ( Safety and Buildings Division Dane <br /> A Ln�t 201 /fl ,Washington Ave.,P.O.Box 7162 -Sanitary Permit Number(to be filled in by Co.) <br /> t. ' , S EP 3 2013 tMadison,Wl 53707-7162 <br /> ;`- r, ' :: T _• + State Transaction Number C/{ <br /> S5rntarp-?erii i ;A.ppl>ication <br /> In accordance with SPS 383.21(2),Wis.Aden Code,submission of this form to the appropriate governmental unit <br /> is required prior to obtaining a sanitary permit. Note:Application forms for state-owned POWTS are submitted to Project Address(if different than mailing address) <br /> the Department of Safety and Professional Servies. Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,a.15.t14(IXm),Stats. Schneider Road <br /> L Application Information-Please Print All Information <br /> Property Owner's Parcel O Name <br /> LLC 0808-353-9150-0 <br /> Property Owner's Mailing Address Property Location <br /> 4605 Evergreen Road Govt.Lot <br /> City,State Zp Code - Phone Number NW g, SW ,6, Section 35 <br /> Middleton,WI 53562 8 N; <br /> IL Type of Building(check all that apply) Lot# T $ N; R 8 E or W <br /> ❑ior 2 Family Dwelling-Number of Bedrooms 1 Subdivision Name <br /> Offices/Storage <br /> Block# <br /> ®Public/Commercial-Describe Use ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of <br /> 13210 ES Town of Springfield <br /> III.Type of Permit (Check only one box on line A. Complete line B if applicable) <br /> A. New System ❑Replacement System ❑Treatment/folding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B- ❑Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New List PrCV1O1rs Permit Number and Date Issued <br /> Before Expiration Owner <br /> 1 <br /> IV.Type of POW IS S System/Component/Device: (Check all that apply) <br /> ❑Non-Pressurized In-Ground 0 Pressurized In-Ground ❑At-Grade Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) - Design Soil App• lion Rate(gpdsf) - Dispersal Area Required(s1) Dispersal Area Proposed(sf) System Elevation <br /> 1890 • 0--(t 1,f' I 4J S' a 99.73, 100.33, 100.93' <br /> VI.Tank Info l Capacity in Total #i of Manufacturer <br /> U <br /> Gallons Gallons Units _R <br /> New Tanks ' Existing Tanks i s u 1 <br /> a V urn Cl) tr.O a. <br /> Septic 0r Holding Task 5100 5100 3 ' Meade x <br /> Dosing Chamber 1000 1000 1 Meade x <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Prim) Plumber's Signature • MP/MPRS Number ' Business Phone Number <br /> A r i d .. to.M e iotZ ..,4,e w, og- e3/- /.6.a <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 103/ 3 Grit "'1 (A.),a-„ ,✓tv (rte c v, 5.355-7 <br /> VIII.County/Department Use Only <br /> `Approved ❑Disapproved <br /> Permit Fee Date Issued Isar' t Signature (� <br /> ❑Owner Given Reason for Denial 5/✓ 1. T-43-43 X,�C/ <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> l” ff ( ! Attach to complete plans for the system wed submit to the County only oar paper not lets than 8 tit x 11 twists la stze <br /> fhK- 1, �! f 996 ._ Peril' <br /> SBD-6398(R.11/ 1) 4 3.25•, Re vj eIj <br /> `# /3Z1- -- <br />